In April Dr Leonid Shapiro, managing partner at Candesic, wrote about the possible impact of Covid-19 on care homes. He now offers additional thoughts on the future of the sector and ideas of how we might solve the coronavirus problem in care homes. Firstly, some home truths.
Most care homes are now unprofitable. That is a sad but true fact.
An estimated 20,000 residents have been lost to Covid-19, representing 5% of care home residents. This, coupled with the near absence of new admissions, has pushed most care homes to a level of occupancy where they cannot make money.
Taking an 18-month average length of stay, two months of no admissions means that one-ninth (11%) of residents’ beds have become unfilled. Combine this with 5% of excess deaths due to Covid-19 equates to over 15% of occupancy loss. This is enough to turn even top performing care homes loss making.
At the same time, care homes costs have increased. Most are paying five times more for personal protective equipment (PPE) than before Covid. Many are struggling with staff sickness and higher agency costs. This further insult to injury is making practically every care home in the UK, except perhaps those few who have managed to avoid Covid, unprofitable.
Government grants for infection control will only scratch the surface
The government’s pledge to spend £600m on infection control in care homes has been welcomed, but many operators are concerned that this money will not reach the front line. It may serve to alleviate some of the costs of PPE, but it won’t help with occupancy, which is the key driver of profitability and sustainability of a care home.
Operators must convince potential residents they will be safe
To attract new care home residents to fill those empty beds, operators need to convince potential residents that not only is their home safe, but that it is safer than residents being in their own home.
It is not just about showing potential residents the operator is doing all they can to disinfect and prevent infection. Instead, it is showing that the care home is the safest place for elderly people and those with underlying conditions to live. There are inherent things that can be done in care home environments that can’t be done with homecare.
Operators must focus on these to create a conviction for older people to make the choice to move.
Life in a care homes must be ‘livable’
Safety should not be at the expense of isolation. Banning family members may be effective from a safety point of view but it is unacceptable from a living point of view and families will reject care homes where their loved one will be isolated from them. For potential residents and their families to choose to move into care homes will require operators to create an environment without the aseptic feel of PPE and the prisoner feel of isolation.
So how can operators solve these issues and do so quickly?
Operators must turn their care homes into Covid-free spaces
Much like operating theatres in hospitals, aseptic compounding in pharmacies, and dust free ‘fabs’ of chip manufacturers have created mechanisms to seal off and protect specialised environments, care homes need to seal off and keep their entire home protected from Covid-19.
To date, protection has come from banning unnecessary visitors and establishing barrier protection between people in the care home. This is not sustainable, from either a resident and family point of view or from the carers’ perspective. Instead, care homes must shift the protection to the home itself.
Having a Covid-free home will mean reduced or no use of PPE, saving money for operators and fostering a more ‘livable’ environment for residents.
All care home staff should be tested for active infection daily
Staff are the primary source of Covid infection in care homes. What makes Covid-19 particularly contagious is its long incubation period and the many asymptomatic carriers it creates. Most transmission is by people who are infected but do not show symptoms.
By the time symptoms are present, the damage has been done. Some operators have adopted a policy to move their staff into their care homes. This has worked but it has proven unsustainable. Staff may be prepared to do this during a lockdown but not in normal life.
Until a reliable vaccine is developed or we have enough immune care workers, the only way to control Covid entering the home is by daily staff testing. Taking a 1:1 ratio of residents to staff, there are some 400,000 staff in the elderly care home sector. Testing them daily is impractical with current methods.
The government is barely able to test 100,000 people per day across the entire population. Clearly there is not enough capacity and the cost of daily testing would be impractical. PCR (polymerise chain reaction) tests cost approximately £25 each in volume.
However, mass parallel testing could be a solution (Figure 1).
Due to the extremely high sensitivity of PCR testing, even a very small amount of virus can be detected in a swab sample. PCR is so sensitive, that swabs from multiple people, such as entire care home’s staff, can be tested as one sample at the same time.
So for £25, care homes can test their entire, say 20 or 30 staff members, by combining their samples into one sample to test. This, of course, will only tell if one of those staff members has Covid but not tell which one. However, in most cases this is sufficient.
In the situation where the test is positive, the home can be put on alert and PPE dawned and all staff can be individually tested to find the carrier.
All residents should be tested weekly
Equally so, resident should be tested regularly in the same way. One test for all followed up with one test each if positive. With overnight results this two-step process will take less than 48 hours to identify those infected. Furthermore, PCR takes only a few hours so with better logistics or even point of care machines (costing under £5,000) located in care homes could reduce this to 12 hours.
Positive residents need to be isolated, ideally outside the care home. Larger operators can designate a ‘hot’ ward or floor in a care home locally to receive all positive residents and where full PPE is used.
The remaining care homes can then be ‘cold’ and Covid-free. This way of concentrating positive residents will make use of PPE more cost effective and enable better and more tailored care for these residents.
New residents tested 48 hours prior to admission
This is what is happening now and this should continue. Those who have been treated for Covid and leaving hospital require two negative tests before they can be transferred to care homes. Those coming from the community need to test negative themselves along with their family members prior to admission (can be done with the same parallel method).
Testing family visitors 48 hours prior to visit
Similarly, anybody visiting the home should be tested in the same way. This must be extended to everybody, from maintenance workers to Care Quality Commission inspectors.
All deliveries to be passed through UV disinfection or to stand isolated for
The other way Covid can enter the home is through fomites. These are objects or materials which are likely to carry infection, such as clothes, utensils, packaging, etc.
To reduce this risk, all deliveries need to be either sterilised or left to self-sterilise (the virus does not survive outside the body typically for more than a couple of days). It is relatively inexpensive to buy a UV conveyer belt and pass any deliveries, such as food, utensils, PPE boxes, etc. through for immediate use (Figure 2). For those homes who have space, items can be left for three days to self-sterilise.
Strict hand sanitation process
Despite a negative test, all visitors still need to ensure they sanitise their hands and that their belongings are passed through the UV machine.
Taking these steps together will create a safe and pleasant environment for staff and residents alike. Visitors will not need to wear masks, staff can avoid PPE, and residents can live a relaxed life with less worry about getting Covid-19 than if they were living in their own home.
Such a scenario could turn around the occupancy crisis care homes are facing and might just make them more popular than they were before Covid-19.
Imagine a world where care homes are not just for people who are unable to not look after themselves but for anyone who is high risk who wants to live in a safe and worry-free environment. This could indeed be a revolution for the sector, dramatically increasing demand and occupancy.
Imagine new care homes built with UV stations throughout, disinfection corridors and entry halls, and even negative pressure ventilation to reduce air movement between rooms and special anti-viral air filtration system.
Imagine onsite point of care PCR testing where staff are tested as they clock in. Such care homes of the future may become the new norm and serve to massively grow the market.
Even if Covid-19 is eliminated, this approach could be used to keep the common flu, which is still a major killer of older people, out of care homes. Are we peering into what the new normal might look like?
Dr Leonid Shapiro is a medical doctor and managing partner of Candesic, a health and social care consultancy serving operators, investors, and the NHS.